Report of the 2013 AMCP Partnership Forum on Electronic Solutions to Medication Reconciliation and Improving Transitions of Care

BACKGROUND: The Affordable Care Act (ACA) is driving the evolution of reimbursement from a fee-for-service model to an outcomes-based system. Accountable care organizations (ACOs) are 1 component of this evolution, and 1 of their charges is to reduce hospital readmission rates for key diagnoses such as congestive heart failure (CHF) and other cardiovascular comorbidities. Lack of patient follow-up and adherence are 2 major causes of readmission. Providing strong medication management is 1 of the common factors in successful readmission programs. We discuss here how electronic solutions might strengthen these medication management programs. OBJECTIVES: To explore the key issues and strategies that affect the use of electronic medication reconciliation processes and to identify the role the Academy of Managed Care Pharmacy (AMCP) can play in spearheading the adoption of electronic solutions. METHODS: This was a descriptive analysis of the medication reconciliation process and the factors that promote or limit the application of electronic solutions to medication reconciliation and transitions of care processes. AMCP convened a panel of managed care, hospital, community, ACO, and medication therapy management pharmacists; technology vendors; and other health care stakeholders with an expertise or interest in transitions of care. RESULTS: In the last few years, there has been considerable uptake of electronic solutions to the admission medication reconciliation process, largely due to increasing penetration of vendors using sophisticated medication history tools. The current electronic solutions to the admission medication reconciliation record are remarkably similar in content. Some pilots for electronic solutions to discharge medication reconciliation are emerging. CONCLUSIONS: The focus group recommended specific programs AMCP can pursue to increase the adoption of electronic solutions for medication reconciliation. One important aspect to address is developing a business case that documents the return on investment (ROI) for electronic solutions. Besides electronic efficiencies, the ROI needs to include hospital readmission penalties, loss of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) incentives, avoidance of duplicative efforts, and payer costs for readmissions. Managed care pharmacy needs to be engaged in assessing its incentives for promoting electronic solutions.

T he Affordable Care Act (ACA) is driving the evolution of reimbursement from a fee-for-service model to an outcomes-based system. Accountable care organizations (ACOs) are 1 component of this evolution, and 1 of their charges is to reduce hospital readmission rates for key diagnoses such as congestive heart failure (CHF) and other cardiovascular comorbidities. In June 2013, the Academy of Managed Care Pharmacy (AMCP) convened a Partnership Forum to explore how managed care pharmacy departments can work with their medication therapy management (MTM), ACO, community, and hospital pharmacists to collaborate in redesigning the Medication Reconciliation (MedRec) process for transitions of care. The Partnership Forum focused on electronic solutions to the MedRec process at admission and discharge, including the provision of key clinical assessment data. To make the discussion more meaningful, the discussion concentrated on CHF readmissions, since CHF is the leading contender for preventable readmissions. While this Partnership Forum focused on electronic solutions, the MedRec models reviewed by the panel underscored the need for MedRec to be defined by more than providing a medication list and to include assessment of drug therapy problems (DTP) and development of comprehensive medication action plans (MAP). The panel's premise was that by providing electronic solutions to the "medication list" component of MedRec, the DTP and MAP components of MedRec would be able to receive greater attention.
■■ Background Improving transitions of care and readmissions rates has been a goal in the health care community for years. With the passage of the ACA, several programs are being initiated to facilitate the improvement of patient outcomes, including readmission rates. Improving quality, safety, and affordability of health care is the basis under which the act was created.

Partnership for Patients
Among CMMI-funded programs is Partnership for Patients (PfP), a public-private partnership whose 3-year 2013 goal is to reduce hospital readmissions by 20% and hospital-acquired conditions by 40%. The PfP program has 2 primary mechanisms for driving its readmissions efforts: 1. The Community-Based Care Transitions Program, which tests care programs designed to improve care transitions and reduce readmissions for high-risk Medicare members and has 102 participating organizations. 2. Hospital Engagement Networks (HENs), which are 26 organizations working with over 3,700 hospitals across the country to identify measurable solutions to reduce hospital-acquired conditions and working to spread those solutions to other hospitals and health care providers. 1

Respondents (%)
A D for high-risk enrollees. In 75% of the successful programs, the 6 common elements were as follows: 1. Supplementing telephone calls to patients with frequent face-to-face meetings. 2. Occasionally meeting face-to-face with providers. 3. Acting as a communications hub for providers. 4. Delivering evidence-based education to patients. 5. Providing strong medication management. 6. Providing timely and comprehensive transitional care after hospitalizations.
The Agency for Healthcare Research and Quality (AHRQ) Match Handbook sees electronic solutions as an important component of readmission strategies and recommends developing "a single medication list ('One Source of Truth'), shared by all disciplines for documenting the patient's current medications." 11 AHRQ characterizes the Match approach, a stepwise approach to redesigning MedRec, as making "the right thing to do the easy thing to do." 11 These studies and reviews [8][9][10][11][12] underscore that providing strong medication management is 1 of the common factors in successful readmission programs and that attention to MedRec alone could bring most hospitals out of the readmission penalty range with CMS. 2

Medicare Readmissions Penalty
The inability to reduce readmission is no longer just a dilemma for patients and payers. The Readmissions Reduction Program (RRP), another program facilitated by the ACA, subjects hospitals to Medicare readmissions penalties (MRP). Effective October 2012, the RRP reduces payments to hospitals with excess readmissions.
The MRP defines a readmission as an admission to a hospital within 30 days of a discharge from the same or another hospital. 13 In the first year of implementation, 67% of hospitals were penalized at an average of $125,000 per hospital. The maximum penalty, capped at 1% and 2% for 2012 and 2013, respectively, was levied on 9% of hospitals. 2 These penalties can be a source of major loss of capital and can be devastating to many health systems and smaller hospitals, wiping out capital budgets, for example. Hence, the MRP gets a lot of attention from the hospital community. The fact that the penalty could be based on readmission following discharge from another hospital underscores the need to have comprehensive data exchange to assist providers in readily identifying high-risk patients.

Hospital Value-Based Purchasing Incentives and HCAHPS
The Hospital Value-Based Purchasing (VBP) program is an ACA-facilitated program that provides incentives to hospitals to provide quality service to its patients. VBP incentive payments are tied to reduction in readmissions as well as responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys. Prior to the HCAHPS standardized survey methodology, there was no national standard for collecting or publicly reporting patients' perceptions of the hospital care they received. 14 HCAHPS scores determine 30% of the Medicare VBP incentive calculation. Of the 14 HCAHPS questions, there are 2 each for discharge instructions; communication about medications; and pain management. In 2013, 3 new questions were added to the survey addressing these topics: 15  In 2015, HCAHPS will continue to be 30% of the VBP calculation, but process measures will reduce from 45% to 20%, and a greater emphasis will be given to efficiency. According to Schulke (2013), it is striking that the HCAHPS and readmission teams in hospitals often are not coordinating their activities, despite the fact that preparing for discharge and educating the patient about medications are integral to both efforts. 2 In addition to the need to improve communication with patients, hospitals need to consistently communicate with the patient's physician after discharge. Many patients (41%) are discharged with test results pending, and physicians are often (61%) unaware of the results when they are reported. One study found these results would have altered the patient's care for 10% of patients. Direct communication between hospital physicians and primary care physicians is rare (3%-20%), and discharge summaries seldom are available at the first postdischarge physician visit, including important changes to drug therapy (12%-34%). 16

■■ Best Practice Medication Reconciliation
Despite reports from more than a decade ago that most hospitals do not directly involve pharmacists in obtaining medication histories, the practice continues. 17 Bond et al. (2002) reported a 51% reduction in medication errors when pharmacists took charge of MedRec. 16 Another study, , found 38% of medication histories taken by nonpharmacists had at least 1 medication discrepancy, and for those discrepancies requiring intervention, 42% omitted at least 1 medication. 18 The same study found that cardiovascular medications accounted for 12% of the medication discrepancies requiring intervention. 18 One study at a 760-bed tertiary-care referral center found that without electronic sources of medication history, nurses spent an average of 14 minutes obtaining histories, while pharmacists are reported to spend 11-13 minutes but effect a higher percentage of clinical interventions (34% vs. 16%). 19 Including clinical pharmacists in discharge procedures, MedRec reduces medication-related errors, reduces hospital and emergency department (ED) visits and hospital readmissions, and improves the overall quality of patient care. [20][21][22][23][24][25][26][27][28][29][30] In addition, the closer the discharge intervention to the date of discharge, the greater the reduction in number of readmissions. 30 A recent study of transitions of care services involving clinical pharmacists found readmissions cut for 1 in 6 patients overall and 1 in 3 for high-risk patients. 31 In 1 study, the impact of pharmacists was not found to be as significant when usual care discharge included a nurse telephone call within 3 days of discharge. 25 Patients most at risk for ADEs postdischarge include those who are doing the following: 24 1. Receiving 5 or more chronic medications at discharge. 2. Receiving 1 or more of the following medications: digoxin, diuretics, anticoagulants, sedatives, opioids, asthma or chronic obstructive pulmonary disease (COPD) drugs, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers. 3. Requiring drug-specific monitoring (electrolyte supplements, anticonvulsants, immunosuppressants). 4. Having > 2 drug therapies added, discontinued, or changed during the admission. 5. Having documented dementia or confusion. 6. Unable to manage their own medications.
To ensure complete MedRec for all high-risk patients, some hospitals with limited inpatient pharmacist availability are engaging pharmacists from other sources, including the following: 2,32 1. Pharmacists in outpatient hospital pharmacies and hospital clinics. 2. Community MTM pharmacists. 3. Walgreens "Well Transitions" program, which delivers medications to patients before discharge. 4. Home health agency pharmacists.
There are several barriers to making these care transitions partnerships effective at reducing readmissions, including the following: 1. Hospital silos and lack of coordination of MedRec processes with HCAHPS survey processes. 2. Lack of a robust and timely (1-3 days) discharge MedRec process that includes medication delivery and communication with patients, caregivers, physician offices, and community pharmacies. 3. Lack of coordination with MTM pharmacists. 4. Slow uptake of available electronic solutions to provide a complete MedRec record at admission and discharge. 5. Lack of feedback to hospitals on ineffective discharge processes.
According to the AHA/HRET, hospitals are actively looking for ways to connect hospital staff to outpatient pharmacists, whether it is an MTM pharmacist, home health agency pharmacist, or community pharmacist. They see a role for managed care pharmacists, especially the MTM component, to provide coordination between hospitals and community pharmacies and physician offices. 2 Some managed care organizations (MCO), such as Blue Cross Blue Shield in Colorado, have funded readmission initiatives through the local hospital association. The Medicare Payment Advisory Committee (MEDPAC), an independent Congressional agency created to advise the U.S. Congress on issues affecting the Medicare program, has suggested that health plans align beneficiary decisions with the readmission goals and payment bundling by offering services such as MTM MedRec. 4 MTM providers are experimenting with various approaches to incorporating hospital admission and discharge MedRec processes into the MTM workflow. Figure 2 is an example of an MTM transitions of care process.

■■ Case Study: An Integrated MCO-ACO Model and Readmissions 32
The AHA/HRET HEN is not the only group implementing techniques and procedures to decrease readmissions. In Detroit, Michigan, the Henry Ford Health System (HFHS), 1 of the nation's leading comprehensive, integrated health systems, has implemented various procedures to improve its transitions of care. The HFHS has adopted the structure of an ACO with the development of the Henry Ford Physician Network (HFPN), comprised of approximately 1,200 Henry Ford Medical Group (HFMG) physicians and 500 community practice physicians. HFHS also includes an MCO-Health Alliance Plan (HAP)-with over 660,000 members. Through a collaborative partnership, HFPN, HAP, 4 HFHS hospitals, Henry Ford Home Health Care (HFHHC), and the HFHS/HAP ambulatory clinical pharmacists have made a positive impact on improving outcomes and reducing readmissions.
The HFHS/HAP ambulatory clinical pharmacists are embedded within the HFMG clinics and provide MTM services for HFMG patients and HAP members assigned to their regions, including non-HFMG patients. This relationship has provided them with an opportunity to become an effective partner with the HFPN integrated ACO model to improve health care and medication outcomes. Among the advantages MCO pharmacists gain in the ACO model at HFHS are the following: 1. Ability to view and update the electronic health record (EHR), including the ED and inpatient EHR. 2. Ability to e-prescribe in collaboration with prescribers and order labs. HFHS/HAP MTM pharmacists implement their discharge MTM process within 3-5 days of discharge. Approximately one-third of their time is spent on medication reconciliation and education, and two-thirds of their time is spent on understanding the patient's personal medication goals to determine what motivates/deters the patient from taking medication as prescribed and if acute symptoms related to medications are occurring. The pharmacists collaborate with the patient's prescribers to implement a new medication regimen and document their work in the EHR and/or fax to prescribers not using HFHS EHR. The primary focus is to remedy negative symptoms likely to cause a readmission.
The HFHS/HAP pharmacists provide postdischarge MTM services to patients identified through a daily discharge electronic query. According to a presentation by the managing director of the quality improvement program, the pharmacists have provided MTM services to a total of 1,745 patients (51% engagement rate) in 2012. For the 1,745 engaged patients, urgent drug interventions were identified in 48% of the cases. This work has translated into positive trends for reducing allcause 30-day readmission rates (Figure 3).
Because the trend in patient engagement and number of urgent drug interventions identified was decreasing over the first half of 2012, the HFHS/HAP ambulatory clinical pharmacy team started to work on the development of a transition of medication management referral process for high-risk patients.
In October 2012, their first collaborative transition MTM referral program commenced with HFHHC. Over 3 quarters,

Proposed MTM Readmission Reduction Process Flow
Hospital works with MTM vendor to execute fee-for-service contract and refers patient to community pharmacy MTM pharmacist Other pharmacy team members of HFHS were involved with the development of the transitions of care process in these areas: 1. HFHS community pharmacists visit patients at bedside to deliver discharge medications.

Inpatient pharmacists engage with certain readmission
high-risk patients upon admission.

Inpatient pharmacists engage with certain readmission
high-risk patients upon discharge.
As the various HFHS/HAP pharmacy teams further develop their roles in transitions of care, there is an opportunity for further collaboration between inpatient pharmacists, community pharmacists, and MTM pharmacists.
The key factor in the HAP MTM success was integrated health information. The use of EHR and sharing pharmacy claim data was a pivotal part of the MTM readmission intervention. As a result, this approach is being adapted by more ACOs and HENs.

■■ Methods for Electronic Population of the MedRec Record
While readmission reduction efforts require a multifactorial approach, a common theme when designing MedRec pathways is "aim to create a process that makes data collection and reporting as easy and as timely as possible" and "if the information is available electronically, work with an Information Technologist/Data Specialist to arrange for reports to be compiled and delivered." 33 A common discharge theme is the use of scoring systems such as the Readmission Predictive Model score to predict patients most at risk of readmission. 30   34 This does not mean that the data are supplied electronically, only that a MedRec record is available. In fact, a survey of best practices found bidirectional electronic flow of claim information was consistently not available, and its scarcity doubled or tripled the time spent by pharmacists providing MedRec reports. 35 See Figure 4 for a schematic for bidirectional flow as applied to community pharmacy. 36

Electronic Creation of Admission and Discharge MedRec Records in the EHR
For hospitals not in a system with an integrated inpatient and ambulatory EHR, admission MedRec records can be populated electronically via an HIE, usually using vendor-supplied software. A sample admission MedRec record is shown in Figure 5.
Vendor-supplied admission medication records typically acquire up to 12 months of claims data from an HIE or directly from multiple third-party sources that include pharmacy benefits managers, MCOs, Medicaid, claims of HIEs, most operate with a narrow focus. In health service areas with over 5,000 patients, only 18% met basic operational criteria for exchanging test results, medication lists, outpatient problem lists, and discharge summaries. Expansion requires funding, and providers (i.e., hospitals and physician groups) believe more of the burden should be shouldered by payers. Asking the payers to contribute is based on a "cost savings approach." 34 HIEs operate mostly on a "query model" (69%)-data are automatically sought for a particular patient when needed such as when a patient is in the ED-or a "push model" (64%)specified data are pushed to specific users-or both. Where an EHR is not available, transitions of care solutions are increasingly using a "direct" model for pushing data. Inpatient and outpatient medication lists are exchanged by 48% and 55%, respectively, of HIEs. 34 Regarding the Meaningful Use Stage 2 Core Requirements, 75% of hospitals are reported to be meeting the MedRec processors, and community pharmacy systems. In hospitals, the vendor software uses a Health Level Seven International (HL7) Admission, Discharge, and Transfer (ADT) compliant call to the vendor record or HIE. The vendor software analyzes the claim information from the various sources, eliminates duplicate records, and provides a detailed MedRec record that flags drug interactions and duplicate therapy and reports adherence rates. Some vendors include pharmacist MTM case notes in the transmissions. See Figure 6 for a sample vendor electronic MedRec process. 37 Compliance with the Health Insurance Portability and Accountability Act (HIPAA) and state patient information protection laws is preserved by vendors via data use agreements (DUAs). 31 Hospitals that contract for an admission MedRec record typically have the vendor software interface with the inpatient pharmacy system. This allows for a complete electronic discharge medication record. The discharging physician can more efficiently create a discharge record because frequently only the appropriate "continue" or "do not continue" boxes needs to be checked from the list of admission and hospital medications. The vendor software also can be used for e-prescribing at discharge.
The biggest gap in the electronic discharge process is communication with community pharmacies and physicians. At this point, most discharge processes do not engage electronic solutions and instead generate a paper form to be supplied to the patient. Best results have been found when these forms are transmitted to the primary care practice or used by a pharmacist to deliver postdischarge counseling. 38

Central Indiana HIE with Prescription Drug Monitoring Program Approach
Among the Beacon Communities piloting readmission projects, the Indiana Quality Health First (QHF) approach stands out for its proven technical approaches and a resulting 17.3% reduction in readmission rates. The QHF is built on the Indiana HIE and the state prescription drug monitoring program (PDMP). 39 MCOs such as WellPoint use QHF results in their physician incentive programs. 4,40 Piloted as part of an Office of the National Coordinator for Health Information Technology project, 5 of the 6 pilot sites are still operational.
The key difference in this pilot was electronic integration of the state PDMP data with electronic pharmacy claim data. One pilot at Wishard Memorial Hospital in Indianapolis showed that 58% of physicians prescribed fewer controlled substances because they had easier access to the data. 41

■■ Partnership Observations
The AMCP focus group observed that managed care pharmacy departments have a unique opportunity to work with their MTM, ACO, community, and hospital pharmacists to collaborate in redesigning the MedRec process for patients with CHF and other cardiovascular comorbidities. CHF and related comorbidities are of particular interest because of the   readmission penalties accruing to hospitals. The focus group also noted that most managed care pharmacists are not aware of the considerable increase in the last few years of electronic solutions to admission MedRec records, largely due to ongoing penetration of vendors such as HCS, Relay Health, Innovalon, Epic, and Cerner. The focus group further noted that it is important for managed care pharmacists to understand that HIPAA regulations do not preclude this exchange of electronic information per the protections of ADT and DUAs that vendors are sophisticated at implementing.
Despite not having nationally endorsed content specifications, the current electronic solutions to the admission MedRec record are remarkably similar in the data elements they include: drug name, form, and strength; quantity dispensed and days supply; inferred directions (e.g., take twice daily based on quantity/days supply quotient); original and last fill date, frequency of refills, and number of refills remaining; calculated adherence rate; and the identity of the community pharmacy and physician. In addition, most vendors flag drug interactions and duplicate therapy.
Data elements typically not included in the current electronic solutions, except when the hospital has an integrated inpatient and ambulatory EHR, are as follows: over-the-counter medications, social drug use, medication allergies, and an MTM comprehensive medication review (CMR) record. (MTM and CMR are referred to in the generic sense and are not restricted to the Part D definition.) Cash prescription transactions frequently are captured through community pharmacy DUAs. With the exception of CMR records, most hospitals supplement the electronic record with these missing elements based on patient interviews conducted by prescribers, nurses, or pharmacists. Patient interviews also are used to verify the information supplied electronically. The AMCP focus group believes there is no good substitute for the electronic sharing of CMR data: MTM providers need to ensure that HIEs contain the CMR record. Furthermore, since medication omissions are a primary driver of readmissions, without a CMR, knowledge of additionally needed drugs will be missed. Unless the hospital's electronic MedRec record has an interface to the ambulatory medical EHR or CMR, there are several other important pieces of information that are not supplied by pharmacy claims: diagnoses including comorbid states; allergies and previous ADEs; barriers to compliance; identification of nonprescribing health care providers; and patient access to devices (peak flow meters, blood pressure cuffs, diabetic monitors).
The AMCP focus group noted that for CHF, the MedRec process should be owned by the pharmacy and should be executed prospectively and continuously. Explicit time frames for completion of MedRec and for other components of a CMR should be implemented. Additionally, discharge records should be sent electronically to the MCO for coordination with MTM pharmacists and case managers. The general consensus was that expecting the broad community pharmacy stakeholders to assume this discharge role is premature and that MCO MTM programs are a better starting place.
For CHF, it was recommended that the pharmacist be involved at the time of admission, at discharge, and 2-4 days postdischarge. The pharmacy MedRec process should explicitly identify handoffs to other providers and avoid service duplications. Supporting roles for pharmacy technicians also should be identified (e.g., scheduling of patient follow-ups).
Assuming hospitals have access to an electronic solution for admission hospital MedRec, the biggest gap for CHF patients is at discharge. MCOs frequently are trying to coordinate the postdischarge care of CHF patients but are not engaging the MCO's MTM programs. Hospitals generally do not think of payers when developing discharge processes; therefore, services are often duplicated. Electronic handoff of discharge records to MCOs and their MTM pharmacists should be mapped. The MCO's MTM pharmacist should coordinate discharge activities with the patient's physician and community pharmacist. Models where the patient is given discharge medications before leaving the hospital show promise and should be considered.
Pharmacists performing MedRec for CHF should have experience with CHF and training in disease management and patient and health care team communications. Training should address health literacy and overcoming cultural barriers. Certification is good but cannot be the sole criteria for provision of these services and is no substitute for experience treating patients with CHF.
For disease states other than CHF, the profession should recommend use of predictive models to determine diagnoses and comorbidities for which pharmacist involvement is paramount.
Where hospitals have not yet implemented an electronic solution to admission MedRec, there is increasing pressure to improve the process due to CMS readmission penalties and HCAHPS incentives. For the most part, MCOs have not been engaged in assessing their incentives for promoting electronic solutions. The key for MCO administrators is to prove a correlation with a drop in readmission costs or improvement in STARS or adherence scores to redesigns in systemwide readmission procedures, of which the electronic solution is only 1 component.

■■ Recommendations for AMCP Activities
The AMCP Partnership Forum on Improving Transitions of Care identified the following activities in which AMCP should consider engaging: 1. Encourage the implementation of electronic solutions to the MedRec processes. a. Start by educating the managed care pharmacy community about the hundreds of hospitals and ACOs that are using pharmacy claim data to electronically populate the MedRec record. b. Host webinars to educate managed care pharmacists about current bidirectional electronic solutions and the role MTM services can play with the current focus of many hospitals on discharge processes (e.g., bedside prescription delivery, pharmacist coordination of services within 1-4 days postdischarge).